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Date <br />Dote <br />(hoot InspoctIon By <br />DootructIon Inspection By <br />Commettt•• <br />Date Pump Inapeellon By <br />APPLICATION FOR WELL/PUMP PER <br />SA. )AQUIN COUNTY PUBLIC HEALTH ShE.CES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />503 EAsT TENTH sTREET <br />OWNER'S NAME COUN T y OF SAW TOAQVIN ADDRESS 222 E. WEBER AVE., E7TF4 FLOOR PHONE #(10 9)40 -8910 sroc(tToN, C A 9 5 7 0 1 CONTRACTOR FISCH ENVIRONMENTAL ADDRESS159 5HEArs PLACE ucs C -51- PHONE S(209)112 -3510 <br />vALLEY SPRING-5 CA 613 3 13 6 5 SUB CONTRACTOR ADDRESS 9525'2 (JCS PHONE I <br />TYPE OF WELUPUMP: 0 NEW WELL <br />El INSTALLATION <br />o New El Repel,- <br />(TYPE OF PUMP) <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />MONITORING VVELL • OTHER G.E0fROBE <br />CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL <br />DEPTH PUMP SET FT. FIRST WATER LEVEL <br />ID OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL <br /> 0 SOIL BORING <br />1:1 DESTRUCTION! <br />JOB ADDRESS/OR APNS CITY TRACY PARCEL SIZE/APNS 235 -19-13 <br />INTENDED USE <br />El INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />ID GRAVEL PACK/SIZE <br />CI DRIVEN <br />0 OTHER <br />2.0 FT. <br />CONSTRUCTION SPECIFICATIONS A <br />DIA. OF WELL EXCAVATION 2-11V. DIA. OF CONDUCTOR CASINO NA 0 <br />TYPE OF CASING/STEEL/PVC N A DIA. OF WELL CASINO N A D <br />DEPTH OF GROUT SEAL TOT A L DEPTH SPECIFICATION NA a <br />GROUT SEAL INSTALLED BY CO N 1- R A CT OR GROUT BRAND NAME E <br />GROUT SEAL PUMPED: NY.. ON° CONCRETE PEDESTAL BY DRILLER: 0 Yes N No S <br />LOCKING CHESTER BOX/STOVE PIPE NA s <br />PROPOSED CONSTRUCT1OPUDRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE <br />OTHER (TEOPROBE <br />Soil AND GAoutqpwATER G-(A13 SA 1-kpL1,4(7 / SAME -DAY ABANDoNMENT <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE VVOR( WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE wow FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S tom° OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: " I CERTIFY THAT IN THE PERFORMANCE OF THE wow FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR All, REQUIRED INSPECTIONS AT 12011) 45113423, COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />SIor.w1 X Till. CO NS V L-1- Pt is) 1- ACrENT Date 10129193- <br />T 0 5 EPH PNAIAA&E PLOT PLAN (Drew to SeeleI /kale ' to <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />1. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WAU(S. ON THE PROPERTY OR ADJOINING PROPERTY. <br />SE E <br /> A TT A <br /> <br />14 ED <br />S I T A <br />DEPARTMENT USE ONLY <br />Dote 12} k; Area Application Acoopted By <br />PE CODES FEE INFO AMO UNT REMITTED CHECKS/C ASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NLIMBER INVOICE <br />3f...,11.) 1 3 c(-1 V <s- 3- <br />—r <br />12.6 4) Y <br />-.) jeltifil <br />Pub. Health Serv. - Enviro. 173 (1/97)